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TREASURY DEPARTMENT 
UNITED STATES PUBLIC HEALTH SERVICE 

HUGH S. GUMMING, Surgeon General 



LET THE CHILD DO THE "FOLLOW-UP" 
IN SCHOOL HEALTH WORK 



BY 

EDITH B. LOWRY 

Acting Assistant Surgeon 
United States Public Health Service 



REPRINT No. 735 

FROM THE 

PUBLIC HEALTH REPORTS 

March 17, 1922 
(Pages 631-639) 



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WASHINGTON 

GOVKRNMENT PRINTING OFFICE 

1922 



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I I^ECEIVED I 

AUG 9 t922 ' 



LET THE CHILD DO THE "FOLLOW-UP" IN SCHOOL HEALTH 

WORK.^ 

By Edith B. Lowby, Acting Assistan* Surgeon, United States Public Health Service. 

Medical examination of school children has been carried on in a 
more or less efficient manner in some parts of the country for approx- 
imately 30 years. However, it required the revelations of the World 
War to start the wave of public opinion in favor of general health 
for children. Following the cessation of war activities, public opinion 
has been focused upon the physical condition of the children, as shown 
by the country-wide campaign for their weighing and measurement, 
and by the extensive practice of physical examinations and inspec- 
tions. But, while the need for correction has been established, little 
has been accomplished as yet in the way of results. Moreover, there 
is danger that undirected or misdirected effort, failing in definite 
results and causing annoyance to teachers, may tend to close the 
schools to health activities. 

Investigations proved that although in many cases the physical 
examinations had been made in a satisfactory manner, the correction 
of defects was anything but satisfactory. Notes sent to the parents 
were lost by the wayside or ignored at home; the few public health 
nurses could reach only an infinitesimal portion of the parents by 
home visits, which seemed to be the best method of obtaining results. 
"Lack of trained workers" was the cry everywhere. Efficient 
workers were unattainable even if funds were provided. 

In an effort to discover some method of obtaining results without 
a prohibitive staff of home visitors, many schools were visited where 
physical examinations already had been carried on. Questioning the 
children revealed that the majority of them had forgotten the health 
advice given them, and the teachers were equally ignorant of the 
physical condition of their pupils. Everjrwhere the teachers expressed 
a desire for some form of record of the physical examinations that 
could be left in the schoolroom. The ordinary medical examination 
card was not of much value for this purpose, for the teachers already 
were overburdened with the multiplicity of duties and could not 
spend much time going over cards time and again, even if the records 
on the cards meant anything to them. The teachers, as a rule, were 
as poorly informed on the subject of health as were their pupils. 
In many instances the teachers themselves were in as poor physical 
condition as any of the pupils, some even were found with active 
tuberculosis, and the teacher with perfect teeth was almost as rare as 

iRead at the meeting of the American Medical Association, Boston, June, 1921. Reprint from the 
Public Health Reports, vol. 37, No. 11, Mar. 17, 1922, pp. 631-639. 



2 RECORDS IN SCHOOL, HEALTH WORK. 

the efficient health worker. " Yes ; I know I should go to a dentist," 
was a remark frequently called forth. 

What were we to do about it and what was the solution ? Some- 
where memory brought forth the old saying, "When in Rome do as 
Romans do." This, translated according to present needs, meant, 
"When in the schools, follow the methods of the school people to 
which the children as well as the teachers are accustomed." 

In all lines of education except health, educators have found it 
necessary to set a certain standard for the children toward which 
they can work. For instance, a third-grade child is required to learn 
a certain amount of arithmetic and be able to read certain books. 
He is not given the indefinite instruction to "Learn arithmetic," 
"Learn to read." 

Following this line of thought, the question came whether it were 
possible to set a definite standard of health for the children rather 
than say to them, "Be healthy; be well," without giving them an 
adequate idea of what health meant. 

In the course of child-hygiene investigations by the Service in 
Mississippi it was suggested that a definite requirement be set for 
the health of school children for the current year. This suggestion 
was adopted by the State health department and the State depart- 
ment of education. Later it was adopted by the Kentucky division 
of child hygiene with satisfactory results. 

The requirement outlined is as follows : 

Eyes — 

(a) Vision normal or corrected by glasses. 

(b) No evidence of disease or inflammation. 
Ears — 

(a) Hearing normal. 

(b) No evidence of disease or inflammation. 
Nose — 

(a) No adenoids. 

(b) No other obstruction. 
Throat— 

(a) No diseased or enlarged tonsils. 

(b) No evidence of disease or inflammation. 
Mouth — 

(a) No unfilled cavities in teeth. 

(b) Teeth clean, showing evidence of daily care. 

(c) Gums healthy. 
Skin — 

(a) No eruption. 

(b) Scalp clean, free from scales. 

(c) Scalp free from pediculosis. 
Chest — 

(a) No evidence of disease or inflammation of lungs. 

(b) Chest expansion of at least 2 inches. 
Vaccination — 

Good scar or certificate of recent vaccination for smallpox. 
Nutrition — 

(a) Weight normal or not more than 10 per cent over. 

(b) Negative hookworm report. 

(c) No enlarged spleen (malaria). 



KECORDS IN SCHOOL HEALTH WORK. 3 

No claim is made that this is an ideal health standard, but it is 
claimed to be a standard that should and can be lived up to by every 
person, whether child or adult. The requirement purposely was set 
sufficiently low so that it would be possible for it to be reached by 
practically every child in school who made the effort. For this 
reason, no mention was made of cardiac lesions, for instance, as such 
a condit^n probably could not be corrected by the child. The child 
should not be discouraged by an impossible standard. 

The outline was arranged to take in the more obvious defects and 
does not include many defects that would be noted on a more rigid 
examination, the object being to interest the child in his own health 
and to secure his cooperation in having these more common defects 
corrected. As the health condition of a school improves from year 
to year, the requirement can be raised accordingly. How common 
the defects mentioned in the requirement are in the average school is 
shown by the fact that it is rare to find more than one child in a room 
(with the exception of a few cities) that meets all the requirements. 
The greatest failure was under the requirement for mouth, and the 
failure for throat requirement followed a close second. 

HEALTH SCORE CHART. 

In order to visualize health to the pupils and teachers, to give it a 
definite meaning, a Health Score was devised which tells at a glance 
the physical condition of the children in the room. 

The charts were designed, first, to meet the request of teachers 
for a record to be left in the school and, second, to impress upon the 
children the ideal of health. In other words, ''It is a record in the 
language to which children are accustomed." Charts and stars are 
used in practically every school all over the country. By the use of 
these charts the child himself is stimulated to do ''follow-up work" 
in the home. It is felt that in his desire to "follow the crowd" and 
have a gold star placed before his name, his importunities will be 
more successful in securing the attention of the parents than any 
other method. 

What the Health Score means in the school room is this : The prin- 
cipal of the school is visiting this room and hears a little child read 
very badly. Looking at the Health Record he probably finds that 
the child has no star in the column headed "Eyes." The thought 
comes immediately, " Why, that child has something the matter 
with his eyes." At once health is a vital subject to him. 

On the Health Score a red star indicates that the child was, on 

the original examination, up to the standard in the subject indicated 

at the head of the column. For instance, a red star in the column 

marked "Eyes" indicates that at the time of the first examination 

1C0524°— 22 2 



4 RECORDS IN SCHOOL HEALTH WORK. 

the child's vision was normal or corrected by glasses; also that there 
was no evidence of disease or inflammation. 

Blue stars indicate corrections. For example, if the child had poor 
vision and later had this corrected by glasses, and there was no evi- 
dence of disease or inflammation, he would be entitled to a blue star 
under " Eyes." The two colors simply show graphically whether any 
corrections are being obtained. 

Gold stars are placed before the names of children who have met all 
health requirements, that is, when every space following the child's 
name is filled with either a red or a blue star. 

An especially designed health button may be presented to every 
child who has obtained a gold star. This should be presented with 
as much ceremony as a diploma, for we consider that any child who 
has given the necessary attention to his health to become a gold star 
pupil is entitled to some recognition. 

The following instructions are given for using the Health Score 
Chart, which is intended to be used in connection with the height and 
weight record. 

Names. — The names of the children should be filled in plainly with black ink in the 
same order as the}' appear on the classroom weight chart. The two charts are com- 
panions and should be hung together in the schoolroom in such position that they can 
be seen readily by the pupils. 

Red Star. — Red stars are stamped in the various columns when the child is free 
from defects or is up to the standard of the subject indicated at the head of the column 
at the time of the original medical examination. For example, a red star in the 
column marked "Eyes" indicates that at the first examination the child's vision was 
either normal or had been corrected by glasses, and also that there was no evidence of 
disease or inflammation of the eyes. 

Blue Star. — Blue stars indicate correction. For example, if at the time of the first 
medical examination the child had poor \asion, which was later corrected by glasses, 
and there is no evidence of disease or inflammation, he would be entitled to a blue 
Btar under the heading "Eyes." 

Gold Star. — A gold star is placed in the column in front of the name of the child who 
has met all the health requirements; that is, when every space following the child's 
name is filled with either a red or blue star. 

Two Gold Stars. — Two gold stars may be placed in the column in front of the name of 
the child when it is impossible for the child to obtain relief from certain physical 
defects, even though everything possible has been done. In such a case the child 
may have two gold stars after all other corrections have been made. For example, if 
a child's deafness is such that it is impossible to correct it, even though everything 
possible is done; or if a child suffering from chronic infantile paralysis has met all the 
other requirements of the health score card, then he is entitled to the two gold stars. 

The child should not be given a health button in such case until after conference 
with the director of the State division of child hygiene. 

Health button. — In order further to stimulate the interest of the child in completing 
the health score, an award in addition to the gold star should be made in the form of a 
health button, after the physician in charge of the examination finds that he has 
completed the health score. 

The health button should show the year in which it is given so that if the score ia 
changed another year, or the child develops defects, there will be no question con- 



RECORDS IN SCHOOL HEALTH WORK. 5 

cerning Ms right to wear the button. The health button should be furnished by the 
State division of child hygiene. 

The presentation of a health button should be an occasion of special ceremony, and 
the child's parents should be invited to attend. 

Hoiv to make out the Health Score record. — The health record can be made in the office 
from the school examination cards. It will save time to make the entire chart before 
adding any stars, indicating by " " the space for red stars and then pasting or stamp- 
ing the stars over these letters. 

Every space after a child's name should be marked in some manner, as blank spaces 
will indicate that the exaynination has not been made. 

Indicate by "a," "b," or "c" the defects found, using the Health Score Chart as 
a guide. Example: 

In the column headed "Eyes" — 

If the examination has not been completed, leave this space blank. 

If vision is normal and there is no evidence of disease or inflammation, put an "o" 

in this space. 
If vision is normal but there is some inflammation, use a "b." 
If vision is defective but there is no inflammation or disease, use an "a." 
If vision is defective and there is also inflammation, use "a-6." 
Again, under nutrition, a small "a" will indicate under weight, while a capital "A" 
will indicate those who are over weight for a given age. This will make it easy to 
distinguish the children who are under weight and those who are over weight. 

By using this method it will be easy to make a summary of defects from the chart, 
as by adding all the "a" marks in the colimin under "Eyes" the total number with 
defective \'ision will be found. 

CLASSROOM WEIGHT CHARTS. 

The following instructions are given for the use of the Weight 
Chart: 

Names of the children should be filled in by the teacher in alphabetical order, sur- 
name first. Use black ink. 

Age {nearest birthday) should be filled in by the teacher. Use black ink. 

Height should be recorded in inches. Height should be taken without shoes, as the 
heels of shoes vary in height. Use black ink. 

Normal weight can be found by consulting height and weight tables. The normal 
weight column should be filled in with red ink. 

Monthly weight may be filled in first with pencil, then inked according to the fol- 
lowing directions: 

(a) If a child is of normal weight or not more than 10 per cent above, use red ink. 
This calls attention to the children who have reached the goal. 

(6) If the child is below normal weight or more than 10 per cent above, use black ink. 

Weight should be taken without shoes, coats, or sweaters. 

Late^' weighing. — Arrangements should be made to have the children weighed 
every month, as this will show whether they are improving in nutrition. In some 
cases the nurse or permanent worker will have time to do this; in others the teachers 
will do the weighing; in other cases a committee of two mothers will volunteer for 
this help; sometimes this may be assigned to one of the older pupils. In all cases the 
weighing should be done as nearly as possible on the same day of the month. 

Scales. — Every school building should have good balance scales as a part of the per- 
manent equipment. Do not buy spring scales, as they get out of order easily and are 
not reliable. It is economy to buy good scales. A description of scales and price 



6 RECORDS m SCHOOL HEALTH WORK. 

lists will he furnished from this office on request. The money to buy scales may be 
obtained in several ways, among which are the following: (1) Appropriated from 
school funds- (2) purchased from funds of parent-teacher organization; (3) purchased 
from Christmas seal money; (4) purchased from Junior Red Cross funds; (5) purchased 
by proceeds from entertainment or "tea" given for this purpose. 

These charts are designed to be left in the schoolroom. They are 
supplied by the State. They may be obtained from the United 
States Public Health Service or the Bureau of Education, Department 
of the Interior, Washington, D. C. 



RECORDS IN SCHOOL HEALTH WORK. 



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